It is scary to ‘nudge’ a patient toward an end-of-life decision. But maybe that’s what it means to be a doctor — knowing our patients and helping lead them toward the decisions that are most consistent with their wishes. And nothing is scarier than the status quo.Also new at the Atlantic website today: "Death Is Having a Moment/Fueled by social networking, the growing 'death movement' is a reaction against the sanitization of death that has persisted in American culture since the 1800s."
I've got a feeling death will be having a "moment" until the last of us Baby Boomers has departed.
पोस्ट्स
३३ टिप्पण्या:
Death is the Enemy. Surrendering to the enemy is not a good idea...it is insanity.
Sorry, Doc. I see the tattoo and all but I just happened on this car wreck and I'll do what I can to make sure you get to see your family again. I'm not about to NOT try to save your life because you got a wild hair up your a** back when you were a med student and thought you had all the answers.
How could anyone resist quoting Dylan Thomas' best-known poem?
"Do not go gentle into that good night.
Old age should burn and rave at close of day;
Rage, rage against the dying of the light."
Having worked with many patients in hospice care over the last 30 plus years, death is far less frightening to me. In fact the time before death is of much more concern. Will I be given appropriate levels of medication to ease my suffering? Will my air hunger be controlled, so as not to have increased levels of anxiety and fear? Will my basic needs be met with dignity and kindness by my caregivers? Will my family members honor my wishes? Is my living will up to date? Will I be allowed to die at home in my own bed?
I've seen dying handled beautifully and horrifically.
It's interesting watching the institutional forces line up to start shaming people into accepting death. I'm sure it's entirely a coincidence that this emphasis is occurring right as more of the financial risk is being pushed to the government.
One of the ways European healthcare is superior to ours is how the end of life is handled. They look at two factors -- the efficacy of the available therapy and physical state of the patient to benefit. In general the " do ever thing for 90 year old Aunt Mary," is not an option. Now before you shout "death panels" remember they out live us. Heroic measures are often inferior to letting nature take its course.
I am going to follow Dr. Friedlander's example and visit a tattoo parlor.
My wife is a retired OR nurse. She's adamant about not taking "heroic measures" when the time comes. After what happened last August, I'm coming to her point of view.
Until early August, my mother was a remarkably healthy 85 year old. She wasn't feeling well one week but nothing too serious. Then, on Sunday the 4th, she felt terrible. My sister was finally able to convince her to go to the hospital. They quickly put her into the ICU diagnosed with pneumonia. The next morning, she was in very bad shape. They convinced her to go on a respirator to give the antibiotics a chance to work. Things seemed to improve for the following week. They were giving her a 70% chance of recovery. On the 13th, she took a very serious turn for the worse. Family was flying in to say their goodbyes, but she was in such terrible shape that we removed her from the respirator on the 14th. She died an hour later.
I have no intention of putting my family through that. Nor for that matter do I want to go through that myself. It was a terrible experience for everyone but especially for Mom. This isn't an abstract discussion for me. You can do what you want.
Before the availability of extraordinary or "heroic" measures, wasn't pneumonia considered "the old person's friend"?
What doctor were NOT willing to do to save their OWN lives. From the John Hopkins Precursors Study.
Dad stopped getting out of bed, and pneumonia set in. Morphine helped Dad across the finish line.
CPR is an extraordinary measure?
Most commonly heard regrets of the dying, as reported by Australian hospice nurse Bronnie Ware:
1. I wish I'd had the courage to live a life true to myself, not the life others expected of me.
"This was the most common regret of all. When people realise that their life is almost over and look back clearly on it, it is easy to see how many dreams have gone unfulfilled. Most people had not honoured even a half of their dreams and had to die knowing that it was due to choices they had made, or not made. Health brings a freedom very few realise, until they no longer have it."
2. I wish I hadn't worked so hard.
"This came from every male patient that I nursed. They missed their children's youth and their partner's companionship. Women also spoke of this regret, but as most were from an older generation, many of the female patients had not been breadwinners. All of the men I nursed deeply regretted spending so much of their lives on the treadmill of a work existence."
3. I wish I'd had the courage to express my feelings.
"Many people suppressed their feelings in order to keep peace with others. As a result, they settled for a mediocre existence and never became who they were truly capable of becoming. Many developed illnesses relating to the bitterness and resentment they carried as a result."
4. I wish I had stayed in touch with my friends.
"Often they would not truly realise the full benefits of old friends until their dying weeks and it was not always possible to track them down. Many had become so caught up in their own lives that they had let golden friendships slip by over the years. There were many deep regrets about not giving friendships the time and effort that they deserved. Everyone misses their friends when they are dying."
5. I wish that I had let myself be happier.
"This is a surprisingly common one. Many did not realise until the end that happiness is a choice. They had stayed stuck in old patterns and habits. The so-called 'comfort' of familiarity overflowed into their emotions, as well as their physical lives. Fear of change had them pretending to others, and to their selves, that they were content, when deep within, they longed to laugh properly and have silliness in their life again."
She also reported that universally all men regretted not spending enough time with their children when they were young.
And to follow up on Inga's last comment, I recently read a piece which reported that many, many doctors refuse the sorts of valiant, last ditch efforts they suggest to their patients. Instead, they go home, smoke cigarettes, take morphine, and etc.
The problem with all of this "when my time comes, I'll...." thinking is that you don't know whether it's your time or not until you're actually dead.
For every story of the ill person who went to a hospital, had intervention after intervention, and finally died a pitiful death, there are several stories of someone who was just as sick, had intervention after intervention despite being at death's door, and... recovered fully and lived another ten or twenty or fifty years. Had children, worked, saw their grandkids married, or just lived life.
And somehow, those stories don't get retold as often. The ones we hear are the ones where someone died after weeks or months of painful, expensive treatment. And they're seldom the ones about cute twenty-year-olds; instead, they tend to be about old people, or occasionally disabled babies. In this way we are instructed about which lives have more value.
What this ends up doing is convincing people (whose life isn't the one at stake) that it's fine for them to judge whether that ten or twenty or fifty years will be worth the expense.
I know Dr F, and he is passionate about this. He is the first person I heard use the term "Old Man's Friend" (he is not very PC) for pneumonia. It will come to carrying around a DNR order like a torah scroll. My experience is that DNR orders are linearly related to education. And that most people will never have another visitor after two weeks in the ICU, until they die. 0.02
jaed, I think you have it backwards. There are a lot more old people who had several interventions and died than people who "had intervention after intervention despite being at death's door, and... recovered fully and lived another ten or twenty or fifty years." The second story is also the one most commonly told.
EDH, By the age of 40 (often before), people's bones start thinning. CPR on an old person often breaks ribs. The healing process can be long and painful. Also, contrary to Hollywood convention it is often unsuccessful in reviving people.
So, is this the phase where we're supposed to start discussing whether "Death Panels" are socially positive institutions?
I have no beef with anyone who decides for themselves what level of intervention they want at the end. But it should be a personal decision, not one imposed from the outside. I just agree with Marshal that
Your parents broke the population curve. For the good of the few, you must submit to the death panel, or abortionist, depending on where you are on the evolutionary path.
Roquette Man,
I know Dr F, and he is passionate about this. He is the first person I heard use the term "Old Man's Friend" (he is not very PC) for pneumonia.
Well, my father spent a week in the ICU with pneumonia a few years back, and then another even more perilous week a month later after a relapse, and now he is well, fit, and eager for everything from travel to photography to online courses to political debate (which I try to avoid; we don't agree on much).
He is now 73, and I imagine he'd gladly tell "Dr. F" where to stick his "Old Man's Friend."
This "conversation" is part and parcel of the liberal defense of Obamacare. Remember when Obama was stumping for "bending the cost-curve downward" by eliminating superfluous services. In short order, the urgent need for annual mammograms became, first, a bi-annual need at most, then not needed at all for women of a certain age, then something that is actually harmful-Don't do it! This is the beginning of the liberal politicking to defy common sense and pervert human nature in the service of ideology. Palin was right.
Michelle, 73 isn't THAT old. Especially considering he was, what, 70? Under 70? a few years back?
I think people with children still at home should not have DNR's unless they're terminally ill. Young, healthy people can, of course, recover from things more easily, so that also has to be taken into account. I plan to have one when my health becomes poor, and I'm no longer responsible for other people. I've seen the ICU. No thanks, not unless there's a big chance of recovery or someone depending on me.
And if my health were already in major decline, there is no way I would submit to anything beyond the most mild cancer treatment.
Someone said that 70 (or thereabouts) isn't that old, which I will attest is true. But it wasn't that long ago that I thought it was pretty old. My father died just short of his 67th birthday, and at the time I thought that was too young to die, but not absurdly too young as I now think. The thing that worries some of us "seniors" about the "death panels" is that they'll be dominated by 50-year-old whippersnappers.
Let me tell you why these "studies" are showing supposedly irrational responses about end-of-life decisions. Here's one of the examples:
"Shifting language from ‘do not resuscitate’ to ‘allow a natural death’ also changed the participants’ choices."
What the Hell do they think regular people understand those terms to mean? "Do not resuscitate" sounds like saying, "You could save my life, but don't bother." "Allow a natural death" sounds like, "After all the reasonable attempts to preserve my life have been tried and failed, let me go in peace." Which would YOU choose?
I think doctors do have an important role in helping people make these decisions. I would like my doctor to tell me if CPR is likely to break my ribs and cause me great pain, without being likely to extend my life much. But the doctor's got to talk sense to me, not jargon, to get that across. Then I'll make my decision. Whatever that decision is, it will NOT involve a tattoo.
Godfather--
Take a CPR class, and the nurse (or whoever the teacher is) will tell you, "Press HARD on the chest. We can fix broken ribs, but if the person stays dead, we can't bring 'em back."
You don't mind broken ribs, do you?
That said, the truth is that life is not like what we see on TV. CPR only works 17 percent of the time. When it does work, there can be brain damage due to the time the person was out.
Most of us laypeople have been conditioned to think that doctors really can do miracles all the time just like on TV.
--
The tragedy of our present system, as it regards end of life, is that many people spend their last days in hospitals and/or going through last ditch efforts that even doctors know will only give a few extra days/weeks of life (possibly with much pain for the patients and relatives) when the last weeks/months could be spent at home with loved ones in a home environment. It's often a trade off--You may get six more months, but may involve very stressful procedures that make your quality of life much worse. No easy answers.
In the UK they let people die of natural causes such as dehydration. As if every immobile person wouldn't die if denied water.
I do love that Sarah Palin was the stupidest, most dishonest woman a.live for bringing up death panels. And now, 5 years later, this frank discussion is entering into the public sphere.
A year ago we lost my Dad. He was fortunate to have had all decisions and paperwork in place with Mom, and his wishes were clear to his children. He was 87 and he was ready to go. His breathing problem had taken a steep downturn near the end. The ICU nurses were wonderful, loving and funny with him (he was alert and smiling)... I should get to the point here: HAVE YOUR LIVING WILL WITH YOU WHEN YOU GO TO THE HOSPITAL. MAKE SURE EVERYONE KNOWS WHERE IT IS OR HAS A COPY. We had only one day's lag time on this, and in that interval we felt pressured to put Dad on a respirator by a physician whom we referred to as Dr. Asperger. Yes, I know about transference of anger, from death to poor Dr. A. Even though we all, including Dad, made his wishes clear, THE HOSPITAL NEEDS YOUR PAPERS IN HAND.
Even then, he had not one but two CATscans, without asking us. In fact they took him down at the one time my mom and I were ever out of the room together. Why? He's 87, near death, and you don't need to know really specifically what's going on inside. So you STILL have to take the initiative to say NO MORE on behalf of your loved one. The hospital then helped us to find a hospice for his four remaining days. That place was so wonderful, we joked (even Dad) about it being "heaven's waiting room".
1800s? More like early '20s with the very early beginnings of media-driven youth culture.
some things stick.
Old joke: You'll know the Boomers are aging when you start reading about the hot new funeral homes.
I'll decide for myself, thank you, with no nudge or influence from some institution. And certainly not by being informed by the death cultists like the writers in the Atlantic.
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